Experts call for better services for patients with facial pain

Patients with persistent face pain should be tested to ensure they get the best and most rapid treatment whilst also saving the NHS money, say experts at Newcastle University.

However, for this to work, they add, there needs to be better-structured systems of care put in place.

Persistent orofacial pain which is pain in the face lasting over three months, affects approximately 7% of the UK population. In many cases, patients are seen by different medical and dental practitioners over several months before getting effective treatment.

Now the first study in the UK carrying out a cost analysis of the treatment these patients receive is published today in the Journal of Dental Research.

It has shown that screening patients with a well-established graded chronic pain scale could ensure that those most severely affected immediately receive specialist care — saving money.

The authors say the current average six month cost of care per patient is £642 and they argue this could be substantially reduced by better-structured systems of care and, at the same time, care would be improved.

Persistent orofacial pain

Persistent orofacial pain (POFP) is caused by various conditions that affect the muscles, joints, nerves or blood vessels of the face or mouth. The conditions are all known by different pseudonyms but the most common conditions include Temporomandibular Disorders, Trigeminal Neuralgia, Burning mouth syndrome and Neuropathic pain including nerve pain following wisdom tooth removal or "phantom" tooth pain.

Lead author, Dr Justin Durham, who is Senior Lecturer and NIHR Clinician Scientist at Newcastle University, and Honorary Consultant Oral Surgeon at Newcastle upon Tyne Hospitals NHS Foundation Trust explained: "Pain is not just how it hurts but how it interferes with your everyday life.

"Patients with this type of pain are not seen very often by GPs and dentists, and as a result practitioners can be uncertain of the best route to take to refer patients for treatment.

"This can result in patients being referred to several different branches of health care and dentistry looking for diagnosis and management, but this can continue for several months until a diagnosis is given and appropriate management agreed. This increases the costs to the health service and adds to the inconvenience experienced by patients.

"This is unsatisfactory for patients as they continue to experience substantial problems over this period of time but this might be averted by using an initial test to establish whether specialist treatment should be offered straight away."

High disability, instant treatment

198 patients were recruited to use the well-established seven item questionnaire graded chronic pain scale (GCPS) and were interviewed and completed questionnaires to measure what treatment they had received in the last six months. The results demonstrate that patients ranked as "high" on the GCPS were considered to have significant pain related disability and needed more care.

Costs of healthcare were grouped into three categories: consultation costs (visits to health care professional for discussion); medication costs; appliance (dental or surgical) and intervention costs (dental/medical/surgical). Consultations – the number of visits patients had to make to healthcare practitioners – accounted for the biggest burden of cost because of the current complex care structure for POFP.

The authors highlight that there may have been some problems with recalling use over the last six months and despite the wide sociodemographic range the cohort may not be representative of other populations, however the study supports the findings of previous research.

Hub and spoke solution

Rather than patients having to undertake a protracted search to get a diagnosis or better pain management, the team suggest that an improved service could be offered by using a hub and spoke model. This would mean patients assessed by the graded chronic pain scale as being low disability being seen by a range of health care professionals in regional clinics. Any patient assessed as high disability would be instantly referred to a specialist in a central hub.

Dr Durham adds: "It is likely that this hub and spoke model would be more efficient and effective for patients but can only work if there is investment and enough experts are recruited.

"Ultimately it is likely this model would provide faster, more effective treatment for patients but at a lower cost."

Lead author, Dr Justin Durham is funded by a National Institute for Health Research Clinician Scientist Award.

CASE STUDY: A long wait for patients

For patients with persistent orofacial pain, it can be a long and worrying battle to get the condition diagnosed.

Alison Ellerbrook, 38, from Morpeth, Northumberland, began to get the symptoms in her early 20's.

She said: "I was having a lot of dental work done – fillings and root canal work — but this didn't end the nagging pain. This went on for 12 years and I changed dentist three times as many of them said they couldn't find anything wrong.

"When I was finally referred to a specialist, Dr Durham, I was prescribed a drug more commonly used for epilepsy to help with the neurological pain and within a couple of weeks I felt better.

"Even so at points I can be so desperate that I will ask the dentist to pull a tooth out to take the pain away – the only way I can describe it is like a gnawing pain deep in my face. My specialist understands and advises me to wait and invariably the pain ebbs.

"The most important thing was that someone believed me and I didn't feel like I was going crazy. Just having that pain acknowledged was a huge relief."